Provider Demographics
NPI:1366909822
Name:SOUTHERN SPINE AND SPORT LLC
Entity type:Organization
Organization Name:SOUTHERN SPINE AND SPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD CLINICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:615-758-6422
Mailing Address - Street 1:3055 KIRKLAND CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-8549
Mailing Address - Country:US
Mailing Address - Phone:615-758-6422
Mailing Address - Fax:
Practice Address - Street 1:2530 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3007
Practice Address - Country:US
Practice Address - Phone:615-758-6422
Practice Address - Fax:615-758-6422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4257004OtherBLUE CROSS BLUE SHIELD